As Some Got Free Health Care, Gwen Got Squeezed: An Obamacare Dilemma

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Gwen and Matt Hurd with their son, Harry, at home in Merrimack, N.H. They pay full price for Obamacare coverage, which has gotten so expensive they have considered forgoing health insurance.CreditCreditKayana Szymczak for The New York Times

MERRIMACK, N.H. — Gwen Hurd got the letter just before her shift at the outlet mall. Her health insurance company informed her that coverage for her family of three, purchased through the Affordable Care Act marketplace, would cost almost 60 percent more this year — $1,200 a month.

She and her husband, a contractor, found a less expensive plan, but at $928 a month, it meant giving up date nights and saving for their future. Worse, the new policy required them to spend more than $6,000 per person before it covered much of anything.

“It seems to me that people who earn nothing and contribute nothing get everything for free,” said Ms. Hurd, 30. “And the people who work hard and struggle for every penny barely end up surviving.”

A few miles away in another wooded suburb, Emilia DiCola, 28, an aspiring opera singer who scrapes by with gigs at churches and in local theaters, has no such complaints. She qualifies for Medicaid — free government health insurance that millions more low-income Americans have gained through an expansion of the program under the Affordable Care Act.

“I am very lucky to have the coverage I have,” said Ms. DiCola, who lives with her parents along the Merrimack River in Litchfield.

President Trump’s attempts to undermine the health law have exacerbated a tension at the heart of it — while it aims to provide health coverage for all, the law is far more generous to the poor and near poor than the middle class. By taking steps that hurt the individual insurance market, Mr. Trump has widened the gulf between people who pay full price for their coverage and those who get generous subsidies or free Medicaid. That, in turn, has deepened the resentment that has long simmered among many who do not qualify for government assistance toward those who do.

Such attitudes have helped shift white working-class voters to the right and were integral in the election of President Trump. They underlie the sharp cuts to social welfare programs in the budget proposal he released this week. They help explain why the national debate over health insurance has been so bitter, and why the only government programs with broad support are those that everyone benefits from, Social Security and Medicare.

They are also likely helping fuel the renewed Democratic push for a single-payer system, or at least one that provides broader access to government health insurance.

“Democrats have begun to recognize the political costs of playing into the narrative that they only care about the poor,” said Joan C. Williams, a professor at the University of California Hastings College of Law and author of a recent book, “White Working Class: Overcoming Class Cluelessness in America.”

Many Republican states plan to start requiring many Medicaid recipients to work, volunteer or take job-training classes. Along the same theme, Mr. Trump’s new budget proposal would make it harder for the so-called “able-bodied” poor who don’t work to receive food stamps and public housing.

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Emilia DiCola, an aspiring opera singer living in Litchfield, N.H., is covered by Medicaid. “I am very lucky to have the coverage I have,” she said.CreditKayana Szymczak for The New York Times

Such proposals reflect a “very American” view — that only those who are severely disabled or struck by tragedy deserve government assistance, and that anyone else who gets it is shirking, said Mark Rank, a professor of social work at Washington University in St. Louis.

“Our social safety net is, in general, the weakest of any of the Western industrialized countries because we have these kinds of views,” Mr. Rank said.

Different Paths

The Affordable Care Act was supposed to help, and did, but not for those who earn too much to get financial assistance but are still on a tight budget. About 25,000 New Hampshire residents paid full freight for Obamacare plans last year, according to a legislative report, and their premiums increased by an average 52 percent this year. This group earns more than four times the poverty level — for a family of three, like the Hurds, that’s about $82,000 a year.

Another 29,000 were getting subsidized coverage through the Affordable Care Act marketplace, and many of them have seen their out-of-pocket costs drop this year. That is because when Mr. Trump forced premiums higher by cutting off a type of payment to insurers last fall that the law had guaranteed them, subsidies rose, too. About 53,000 are getting free Medicaid coverage through the health law’s optional expansion of the program.

Ms. Hurd remembers watching a documentary about people signing up for Obamacare coverage last year and bristling when someone who got a big subsidy gushed about the low price.

“I was like, ‘It’s not expensive for you because everybody else is paying for it,’” she said.

She also has problems with the Medicaid “expansion population,” made up of working-age adults who have no disability — particularly those who aren’t working as hard as she and her husband are. Cut off from the help Obamacare provided to everyone under a certain income level, as well as the contributions that employers make toward their employees’ health coverage, she was caught in what she saw as an unduly penalized subset.

Ms. Hurd finished college at the University of Massachusetts, with her parents paying for it, and has a master’s degree in communications, which she got tuition-free while working in admissions at Southern New Hampshire University. She’s been working about 30 hours a week at the outlet mall and a small remodeling firm while looking for a job with good benefits in communications or marketing.

Her husband, Matt, started his contracting business a few years ago and is finishing his undergraduate degree with the help of a loan. They bought a 1750s farmhouse just before they married; Ms. Hurd returned to work when their son, Harry, was eight weeks old.

Though roughly the same age, Ms. DiCola has followed a different course. She dropped out of the Manhattan School of Music in 2009 after her freshman year because she couldn’t keep up with the tuition. Now, to supplement the scant income she gets from singing gigs, she drives for Uber and Lyft a few nights a week, sometimes more, in Boston. She earned about $15,000 last year, making sure she stayed under the threshold to qualify for Medicaid.

“I feel like it’s no different from what corporations do all the time, taking advantage of tax breaks and that sort of thing,” Ms. DiCola, a soprano who talks animatedly about Verdi and Puccini, said of being on Medicaid. “Frankly, if they’re allowed to do it, why shouldn’t I?”

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Gwen works two jobs while Matt operates a general contracting business he started, but their current health insurance costs $928 a month with a $6,000 deductible.CreditKayana Szymczak for The New York Times

Medical care has been easy to access on Medicaid. She got physical therapy for an old injury, and when she needed to have an IUD surgically removed last year, she went to Dartmouth-Hitchcock Medical Center, the state’s most prestigious hospital. She paid for none of it. She spends most of her income on paying off her car, a used 2012 Prius with 160,000 miles on it, and her last outstanding student loan.

“The coverage is actually really good,” she said. “I’m just kind of finding my way, so the health insurance is so helpful.”

For Ms. Hurd, health care has been something to avoid since she and her husband got the marketplace plan shortly after Harry’s birth last year. (Before that, she had a job with benefits but quit because of her difficult pregnancy.) She went to an urgent care clinic for a throat culture last fall because unlike at her primary care practice, she could find out the cost, $150, upfront. And when Harry was up all night sobbing with a fever recently, she hesitated briefly before seeking medical help, again at urgent care.

“That’s ugly,” she said. “I hate that I, even for a moment, considered waiting it out to save money.”

Constantly Close to the Edge

News stories in New Hampshire have stoked the resentment Ms. Hurd and others facing spiking premiums have felt. “Medicaid platinum, silver for the rest,” read a recent headline in The Union Leader, New Hampshire’s largest newspaper. The story was about a report that found Medicaid recipients used health care more aggressively than marketplace customers, presumably because their coverage was free.

Instead of giving its new Medicaid recipients traditional coverage through the program, New Hampshire uses Medicaid funds to buy them private plans through the Obamacare marketplace. The report, by an independent actuarial firm, found that average medical costs for the state’s expansion population were 26 percent higher than for the marketplace’s other customers in 2016.

The firm found this raised average claim costs — a proxy for premiums — for everyone by 14 percent.

One of the conditions that Gov. Chris Sununu has attached to continuing expanded Medicaid here is that most adult recipients without a disability or small children will have to work, volunteer or get job training, at least 20 hours a week. New Hampshire is among eight Republican-controlled states asking the Trump administration for approval to impose work requirements; two others, Kentucky and Indiana, already got permission last month.

Ms. Hurd — who says she thinks “work is everything, honestly” — is elated about the possibility.

“If there were actual repercussions aside from your personal self-worth — like ‘Hey, you may not be able to get the pills you need’ — people might be more inclined to work,” she said.

But research has found that most Medicaid recipients without disabilities, like Ms. DiCola, already work at least part-time.

“I know I live with my parents, but I’m not going on fancy trips or anything like that — I feel guilty when I buy a new lipstick,” she said. She worried when she had the flu in December and lost four days of income, she said, adding, “I’d like not to feel like I’m constantly so close to the edge.”

Ms. DiCola started driving for Uber and Lyft three years ago, after stints at a Panera and a train station cafe. She often shuttles customers around Boston until after midnight, making up to $25 an hour — enough to pay two or three times more than the $87.50 she owes on her student loan each month, plus buy gas. Her days include pitching in on cooking and other household duties, auditions, rehearsals and studying musical scores on her couch, a cat or two by her side. She hopes to get a college degree, find a more stable career and get access to employer health coverage. But for now, with a free place to live and with Medicaid, she said, “I’m able to throw all my money at paying off my debt.”

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Ms. DiCola had to drop out of the Manhattan School of Music in 2009 because she couldn’t keep up with the tuition. She drives for Uber and Lyft a few nights a week, and works sundry singing gigs.CreditKayana Szymczak for The New York Times

Anxiety and Peace of Mind

Ms. Hurd is a former Republican who volunteered for Mitt Romney’s campaign in 2012 and voted for Carly Fiorina in the 2016 primary, but now describes her politics as more libertarian. She’s pro-immigration, not least because she sees immigrants as having strong work ethics. She voted for Hillary Clinton in the general election, she said, because she finds President Trump deeply offensive, a “guy who bullied his way into power.”

Her father, a Trump voter from the Boston suburbs, sends her articles that are critical of the health law, and they resonate with her.

Even members of her own family take advantage of a flawed system, in her view, by getting Medicaid. “They don’t work because they don’t want to, and they get free health insurance.” She said. “What the heck? If my husband and I, who grew up with relatively middle-class backgrounds in wealthy states, know people that mooch off the system in our immediate families, imagine what it’s like elsewhere.”

Ms. DiCola’s father, a solo-practice lawyer, is also a Trump supporter, but she is a liberal Democrat and uneasily aware of the anger and frustration that unsubsidized Obamacare customers are feeling — so much so that at first, she worried about sharing her story with The New York Times and “being dragged through the mud on some 24-hour news channel” for being on Medicaid.

She described her state’s plan to impose work requirements on Medicaid recipients as “poor-shaming.” Her friends show more empathy, she said. When she needed a root canal and crown last year and Medicaid would not have paid for it (dental care is one area that Medicaid does not cover comprehensively, or sometimes at all), she posted about it on Facebook and her friends jumped in to help.

Ms. DiCola doesn’t expect to need much health care this year — just a physical and a new pair of glasses, which Medicaid will cover, she said. Still, she added, “You never know what could come up — my appendix could decide to burst tomorrow.” In which case, Medicaid would cover the emergency room visit, surgery and hospital stay, a huge relief to Ms. DiCola, who became so anxious as Republicans in Congress tried to repeal the Affordable Care Act last summer that she felt physically ill.

Ms. Hurd has had no such peace of mind. A burst appendix would likely cost at least her individual deductible of $6,300.

By late January, Ms. Hurd had begun to believe that the only way for her family to have any access to health care was to drop their insurance and save the $928 a month to spend on care when they need it. Harry’s recent illness had rattled her, and Matt wanted to see a chiropractor for back pain that was threatening his ability to work.

“We can’t afford to both treat his back issues and pay for insurance,” she said one morning. She was crying, and it was time to go to work.

The following week, after months of searching, Ms. Hurd got offered a full-time job with benefits, running social-media marketing for a company that sells plant nutrition products. The Hurds plan on dropping their Obamacare policy in April, when her new coverage, with a $300 monthly premium, should kick in. The deductible — $3,000 per person, up to $6,000 for the family — will still be higher than she’d like, but she didn’t complain. Her indignation seemed to be softening.

“I understand that some people cannot afford health care and shouldn’t just be left to suffer,” she said. “But there has to be a better way than asking a very small amount of people to foot that bill.”